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1. Asthma Care
Quick Reference
DIAGNOSING AND MANAGING ASTHMA
Guidelines from the National Asthma Education
and Prevention Program
INITIAL VISIT
EXPERT PANEL REPORT 3
The goal of this asthma care quick
reference guide is to help clinicians
provide quality care to people who
have asthma.
Quality asthma care involves not only initial diagnosis and
treatment to achieve asthma control, but also long-term,
regular follow-up care to maintain control.
Asthma control focuses on two domains: (1) reducing
impairment—the frequency and intensity of symptoms and
functional limitations currently or recently experienced by a
patient; and (2) reducing risk—the likelihood of future asthma
attacks, progressive decline in lung function (or, for children,
reduced lung growth), or medication side effects.
Diagnose asthma
Assess asthma severity
Initiate medication & demonstrate use
Develop written asthma action plan
Schedule follow-up appointment
FOLLOW-UP VISITS
Achieving and maintaining asthma control requires providing
appropriate medication, addressing environmental factors
that cause worsening symptoms, helping patients learn selfmanagement skills, and monitoring over the long term to
assess control and adjust therapy accordingly.
The diagram (right) illustrates the steps involved in providing
quality asthma care.
This guide summarizes recommendations developed by the
National Asthma Education and Prevention Program’s expert panel
after conducting a systematic review of the scientific literature on
asthma care. See www.nhlbi.nih.gov/guidelines/asthma for the full
report and references. Medications and dosages were updated in
September 2011 for the purposes of this quick reference guide to
reflect currently available asthma medications.
Assess & monitor
asthma control
Schedule next
follow-up
appointment
Review asthma
action plan, revise
as needed
Review medication
technique &
adherence; assess
side effects; review
environmental control
Maintain, step
up, or step down
medication

2. 2
Asthma Care Quick Reference
KEY CLINICAL ACTIVITIES FOR QUALITY ASTHMA CARE
(See complete table in Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma [EPR-3])
Clinical Issue
Key Clinical Activities and Action Steps
ASTHMA DIAGNOSIS
Establish asthma diagnosis.
ƒƒ Determine that symptoms of recurrent airway obstruction are present, based on history
and exam.
••History of cough, recurrent wheezing, recurrent difficulty breathing, recurrent
chest tightness
••Symptoms occur or worsen at night or with exercise, viral infection, exposure to allergens
and irritants, changes in weather, hard laughing or crying, stress, or other factors
ƒƒ In all patients ≥5 years of age, use spirometry to determine that airway obstruction is at
least partially reversible.
ƒƒ Consider other causes of obstruction.
LONG-TERM ASTHMA MANAGEMENT
GOAL:
Asthma Control
Reduce Impairment
ƒƒ Prevent chronic symptoms.
ƒƒ Require infrequent use of short-acting beta2-agonist (SABA).
ƒƒ Maintain (near) normal lung function and normal activity levels.
Reduce Risk
ƒƒ
ƒƒ
ƒƒ
ƒƒ
Assessment
and Monitoring
Prevent exacerbations.
Minimize need for emergency care, hospitalization.
Prevent loss of lung function (or, for children, prevent reduced lung growth).
Minimize adverse effects of therapy.
INITIAL VISIT: Assess asthma severity to initiate treatment (see page 5).
FOLLOW-UP VISITS: Assess asthma control to determine if therapy should be adjusted
(see page 6).
ƒƒ Assess at each visit: asthma control, proper medication technique, written asthma action
plan, patient adherence, patient concerns.
ƒƒ Obtain lung function measures by spirometry at least every 1–2 years; more frequently for
asthma that is not well controlled.
ƒƒ Determine if therapy should be adjusted: Maintain treatment; step up, if needed; step
down, if possible.
Schedule follow-up care.
ƒƒ Asthma is highly variable over time. See patients:
••Every 2–6 weeks while gaining control
••Every 1–6 months to monitor control
••Every 3 months if step down in therapy is anticipated
Use of
Medications
Select medication and delivery devices that meet patient’s needs and circumstances.
ƒƒ Use stepwise approach to identify appropriate treatment options (see page 7).
ƒƒ Inhaled corticosteroids (ICSs) are the most effective long-term control therapy.
ƒƒ When choosing treatment, consider domain of relevance to the patient (risk, impairment,
or both), patient’s history of response to the medication, and willingness and ability to use
the medication.
Review medications, technique, and adherence at each follow-up visit.

3. Asthma Care Quick Reference
KEY CLINICAL ACTIVITIES FOR QUALITY ASTHMA CARE
Clinical Issue
Key Clinical Activities and Action Steps
Patient
Education for
Self-Management
(continued)
Teach patients how to manage their asthma.
ƒƒ Teach and reinforce at each visit:
••Self-monitoring to assess level of asthma control and recognize signs of worsening
asthma (either symptom or peak flow monitoring)
••Taking medication correctly (inhaler technique, use of devices, understanding
difference between long-term control and quick-relief medications)
- Long-term control medications (such as inhaled corticosteroids, which reduce
inflammation) prevent symptoms. Should be taken daily; will not give quick relief.
- Quick-relief medications (short-acting beta2-agonists or SABAs) relax airway
muscles to provide fast relief of symptoms. Will not provide long-term asthma
control. If used >2 days/week (except as needed for exercise-induced asthma),
the patient may need to start or increase long-term control medications.
••Avoiding environmental factors that worsen asthma
Develop a written asthma action plan in partnership with patient/family (sample plan
available at www.nhlbi.nih.gov/health/public/lung/asthma/asthma_actplan.pdf).
ƒƒ Agree on treatment goals.
ƒƒ Teach patients how to use the asthma action plan to:
••Take daily actions to control asthma
••Adjust medications in response to worsening asthma
••Seek medical care as appropriate
ƒƒ Encourage adherence to the asthma action plan.
••Choose treatment that achieves outcomes and addresses preferences important to
the patient/family.
••Review at each visit any success in achieving control, any concerns about treatment,
any difficulties following the plan, and any possible actions to improve adherence.
••Provide encouragement and praise, which builds patient confidence. Encourage family
involvement to provide support.
Integrate education into all points of care involving interactions with patients.
ƒƒ Include members of all health care disciplines (e.g., physicians, pharmacists, nurses, respiratory
therapists, and asthma educators) in providing and reinforcing education at all points of care.
Control of
Environmental
Factors and
Comorbid
Conditions
Recommend ways to control exposures to allergens, irritants, and pollutants that make
asthma worse.
ƒƒ Determine exposures, history of symptoms after exposures, and sensitivities.
(In patients with persistent asthma, use skin or in vitro testing to assess sensitivity to
perennial indoor allergens to which the patient is exposed.)
••Recommend multifaceted approaches to control exposures to which the patient is
sensitive; single steps alone are generally ineffective.
••Advise all asthma patients and all pregnant women to avoid exposure to tobacco smoke.
••Consider allergen immunotherapy by trained personnel for patients with persistent
asthma when there is a clear connection between symptoms and exposure to an
allergen to which the patient is sensitive.
Treat comorbid conditions.
ƒƒ Consider allergic bronchopulmonary aspergillosis, gastroesophageal reflux, obesity,
obstructive sleep apnea, rhinitis and sinusitis, and stress or depression. Treatment of
these conditions may improve asthma control.
ƒƒ Consider inactivated flu vaccine for all patients >6 months of age.
3

4. 4
Asthma Care Quick Reference
ASTHMA CARE FOR SPECIAL CIRCUMSTANCES
Clinical Issue
Key Clinical Activities and Action Steps
Exercise-Induced
Bronchospasm
Prevent EIB.*
ƒƒ Physical activity should be encouraged. For most patients, EIB should not limit
participation in any activity they choose.
ƒƒ Teach patients to take treatment before exercise. SABAs* will prevent EIB in most patients;
LTRAs,* cromolyn, or LABAs* also are protective. Frequent or chronic use of LABA to
prevent EIB is discouraged, as it may disguise poorly controlled persistent asthma.
ƒƒ Consider long-term control medication. EIB often is a marker of inadequate asthma control
and responds well to regular anti-inflammatory therapy.
ƒƒ Encourage a warm-up period or mask or scarf over the mouth for cold-induced EIB.
Pregnancy
Maintain asthma control through pregnancy.
ƒƒ Check asthma control at all prenatal visits. Asthma can worsen or improve during
pregnancy; adjust medications as needed.
ƒƒ Treating asthma with medications is safer for the mother and fetus than having poorly
controlled asthma. Maintaining lung function is important to ensure oxygen supply to the fetus.
ƒƒ ICSs* are the preferred long-term control medication.
ƒƒ Remind patients to avoid exposure to tobacco smoke.
MANAGING EXACERBATIONS
Clinical Issue
Key Clinical Activities and Action Steps
Home Care
Develop a written asthma action plan (see Patient Education for Self-Management, page 3).
Teach patients how to:
ƒƒ Recognize early signs, symptoms, and PEF* measures that indicate worsening asthma.
ƒƒ Adjust medications (increase SABA* and, in some cases, add oral systemic corticosteroids)
and remove or withdraw from environmental factors contributing to the exacerbation.
ƒƒ Monitor response.
ƒƒ Seek medical care if there is serious deterioration or lack of response to treatment.
Give specific instructions on who and when to call.
Urgent or
Emergency Care
Assess severity by lung function measures (for ages ≥5 years), physical examination, and
signs and symptoms.
Treat to relieve hypoxemia and airflow obstruction; reduce airway inflammation.
ƒƒ Use supplemental oxygen as appropriate to correct hypoxemia.
ƒƒ Treat with repetitive or continuous SABA,* with the addition of inhaled ipratropium
bromide in severe exacerbations.
ƒƒ Give oral systemic corticosteroids in moderate or severe exacerbations or for patients who
fail to respond promptly and completely to SABA.
ƒƒ Consider adjunctive treatments, such as intravenous magnesium sulfate or heliox, in severe
exacerbations unresponsive to treatment.
Monitor response with repeat assessment of lung function measures, physical
examination, and signs and symptoms, and, in emergency department, pulse oximetry.
Discharge with medication and patient education:
ƒƒ Medications: SABA, oral systemic corticosteroids; consider starting ICS*
ƒƒ Referral to follow-up care
ƒƒ Asthma discharge plan
ƒƒ Review of inhaler technique and, whenever possible, environmental control measures
*Abbreviations:
EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; LABA, long-acting beta2-agonist; LTRA, leukotriene receptor
antagonist; PEF, peak expiratory flow; SABA, short-acting beta2-agonist.

5. Asthma exacerbations
requiring oral systemic
corticosteroids‡
F
EV1 /FVC
F
EV1 (% predicted)
Lung function
Interference with
normal activity
SABA use for
symptom control
(not to prevent EIB )
Nighttime awakenings
Symptoms
Components of
Severity
Not
applicable
0
Ages
0–4 years
Ages
≥12 years
80%
Normal FEV1
between
exacerbations
85%
Ages
5–11 years
Mild
Ages
≥12 years
≥2 exacerb.
in 6 months,
or wheezing
≥4x per
year lasting
1 day
AND risk
factors for
persistent
asthma
Not
applicable
2 days/week
but not daily
1–2x/month
Normal†
80%
Not
applicable
3–4x/month
Ages
0–4 years
Ages
≥12 years
75–80%
60–80%
Some limitation
Daily
Reduced 5%†
60–80%
1x/week but not nightly
Daily
Ages
5–11 years
Moderate
≥2/year
Step 1
75%
60%
Extremely limited
Step 3
Step 3
Step 3
medium-dose
ICS option
or Step 4
Consider short course of oral systemic corticosteroids.
Step 3
medium-dose
ICS option
For children 0–4 years old, if no clear benefit is observed in 4–6 weeks, consider adjusting therapy or alternate diagnoses.
In 2–6 weeks, depending on severity, assess level of asthma control achieved and adjust therapy as needed.
Step 2
Step 3
Relative annual risk of exacerbations may be related to FEV1 .
Ages
≥12 years
indicate greater underlying disease severity. For treatment purposes, patients with ≥2 exacerbations may be considered to have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.
† Normal FEV1 /FVC by age: 8–19 years, 85%; 20–39 years, 80%; 40–59 years, 75%; 60–80 years, 70%.
D
‡ ata are insufficient to link frequencies of exacerbations with different levels of asthma severity. Generally, more frequent and intense exacerbations (e.g., requiring urgent care, hospital or intensive care admission, and/or oral corticosteroids)
Step 4
or 5
Reduced 5%†
60%
Often 7x/week
Throughout the day
Ages
5–11 years
Severe
Several times per day
Not
applicable
1x/week
Ages
0–4 years
Generally, more frequent and intense events indicate greater severity.
Generally, more frequent and intense events indicate greater severity.
80%
80%
Minor limitation
2 days/week but
not daily and not more
than once on any day
3–4x/month
2 days/week but not daily
Ages
0–4 years
Persistent
Consider severity and interval since last asthma exacerbation. Frequency and severity may fluctuate over time for patients in any severity category.
0–1/year
Normal†
80%
Normal FEV1
between
exacerbations
None
≤2 days/week
≤2x/month
≤2 days/week
Ages
5–11 years
Intermittent
Abbreviations: EIB, exercise-induced bronchospam; FEV1 , forced expiratory volume in 1 second; FVC, forced vital capacity; ICS, inhaled corticosteroid; SABA, short-acting beta2-agonist.
The stepwise approach is meant
to help, not replace, the clinical
decisionmaking needed to meet
individual patient needs.
(See “Stepwise Approach for
Managing Asthma Long Term,”
page 7)
Recommended Step for
Initiating Therapy
Risk
Impairment
Level of severity (Columns 2–5) is determined by events listed in Column 1 for both impairment (frequency and intensity of symptoms and functional limitations) and risk (of
exacerbations). Assess impairment by patient’s or caregiver’s recall of events during the previous 2–4 weeks; assess risk over the last year. Recommendations for initiating therapy
based on level of severity are presented in the last row.
(in patients who are not currently taking long-term control medications)
INITIAL VISIT: CLASSIFYING ASTHMA SEVERITY AND INITIATING THERAPY
Asthma Care Quick Reference
5

6. Ages
≥12 years
80%
≥2/year
16–19
≥1.5
1–2
Not applicable
60–80%
1–3x/week
2 days/week
Ages
≥12 years
Not applicable
Evaluation requires long-term
follow-up care.
Consider severity and interval since last asthma exacerbation.
2–3/year
Not applicable
75–80%
60–80%
2 days/week
Some limitation
≥2x/month
2 days/week or
multiple times on
≤2 days/week
Ages
5–11 years
Not Well Controlled
Not applicable
3/year
Not applicable
Maintain current step.
Consider step down if well controlled for at least
3 months.
Step up at least
1 step
Step up 1 step
3–4
Evaluation requires long-term
follow-up care.
≤15
Not applicable
Reevaluate in 2 weeks to achieve control.
Step up 1–2 steps.
Consider short course of oral systemic corticosteroids.
Before step up in treatment:
Review adherence to medication, inhaler technique, and environmental control. If alternative treatment was used,
discontinue and use preferred treatment for that step. For side effects, consider alternative treatment options.
For children 0–4 years, if no clear benefit observed in 4–6
weeks, consider adjusting therapy or alternative diagnoses.
Reevaluate in 2–6 weeks to achieve control.
Step up 1 step
60%
≥4x/week
Ages
≥12 years
Not applicable
≥2/year
Not applicable
75%
60%
Several times per day
Extremely limited
≥2x/week
Throughout the day
Ages
5–11 years
Very Poorly Controlled
Not applicable
1x/week
Ages
0–4 years
Medication side effects can vary in intensity from none to very troublesome and worrisome.
The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
Evaluation requires long-term
follow-up care.
Regular follow-up every 1–6 months.
Not applicable
0–1/year
Not applicable
Not applicable
1x/month
2 days/week
Ages
0–4 years
indicate poorer asthma control.
M
† inimal important difference: 1.0 for the ATAQ; 0.5 for the ACQ; not determined for the ACT.
‡ ACQ values of 0.76–1.4 are indeterminate regarding well-controlled asthma.
D
§ ata are insufficient to link frequencies of exacerbations with different levels of asthma control.
Generally, more frequent and intense exacerbations (e.g., requiring urgent care, hospital or intensive care admission, and/or oral corticosteroids)
A
bbreviations: ACQ, Asthma Control Questionnaire©; ACT, Asthma Control TestTM; ATAQ, Asthma Therapy Assessment Questionnaire©; EIB, exercise-induced bronchospasm; FVC, forced vital capacity; FEV1, forced expiratory volume in 1 second;
SABA, short-acting beta2-agonist.
The stepwise approach is meant
to help, not replace, the clinical
decisionmaking needed to meet
individual patient needs.
(See “Stepwise Approach for
Managing Asthma Long Term,”
page 7)
Recommended Action
for Treatment
Treatment-related
adverse effects
Reduction in lung
growth/Progressive loss
of lung function
Asthma exacerbations
requiring oral systemic
corticosteroids§
≥20
ACT
0
80%
Not applicable
Not applicable
80%
≤2 days/week
≤0.75‡
Not applicable
Not applicable
None
≤2 days/week but
not more than
once on each day
≤2x/month
≤2 days/week
Ages
5–11 years
Well Controlled
≤1x/month
≤2 days/week
Ages
0–4 years
ACQ
ATAQ
Validated questionnaires†
F
EV1 /FVC
F
EV1 (% predicted)
or peak flow
(% personal best)
Lung function
SABA use for
symptom control
(not to prevent EIB )
Interference with
normal activity
Nighttime awakenings
Symptoms
Components of Control
Level of control (Columns 2–4) is based on the most severe component of impairment (symptoms and functional limitations) or risk (exacerbations). Assess impairment by patient’s or caregiver’s
recall of events listed in Column 1 during the previous 2–4 weeks and by spirometry and/or peak flow measures. Symptom assessment for longer periods should reflect a global assessment,
such as inquiring whether the patient’s asthma is better or worse since the last visit. Assess risk by recall of exacerbations during the previous year and since the last visit. Recommendations for
adjusting therapy based on level of control are presented in the last row.
FOLLOW-UP VISITS: ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY
Impairment
Risk
6
Asthma Care Quick Reference

7. Asthma Care Quick Reference
STEPWISE APPROACH FOR MANAGING ASTHMA LONG TERM
The stepwise approach tailors the selection of medication to the level of asthma severity (see page 5) or asthma control (see page 6).
The stepwise approach is meant to help, not replace, the clinical decisionmaking needed to meet individual patient needs.
ASSESS
CONTROL:
STEP UP IF NEEDED (first, check medication adherence, inhaler technique, environmental control, and comorbidities)
STEP DOWN IF POSSIBLE (and asthma is well controlled for at least 3 months)
STEP 6
STEP 5
STEP 4
STEP 3
STEP 2
STEP 1
At each step: Patient education, environmental control, and management of comorbidities
Intermittent
Asthma
0–4 years of age
Preferred
Treatment†
SABA as
needed
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 3 care or higher is required. Consider consultation at step 2.
low-dose ICS
medium-dose
ICS
medium-dose
ICS
+
either LABA or
montelukast
high-dose ICS
high-dose ICS
either LABA or
montelukast
either LABA or
montelukast
+
+
+
oral corticosteroids
Alternative
Treatment†,‡
cromolyn or
montelukast
If clear benefit is not observed in 4–6 weeks, and medication technique and adherence are satisfactory,
consider adjusting therapy or alternate diagnoses.
Quick-Relief
Medication
ƒƒ SABA as needed for symptoms; intensity of treatment depends on severity of symptoms.
ƒƒ With viral respiratory symptoms: SABA every 4–6 hours up to 24 hours (longer with physician consult). Consider short
course of oral systemic corticosteroids if asthma exacerbation is severe or patient has history of severe exacerbations.
ƒƒ Caution: Frequent use of SABA may indicate the need to step up treatment.
Intermittent
Asthma
5–11 years of age
Preferred
Treatment†
SABA as needed
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 care or higher is required. Consider consultation at step 3.
low-dose ICS
low-dose ICS
+
either LABA,
LTRA, or
theophylline(b)
Alternative
Treatment†,‡
cromolyn, LTRA,
or theophylline§
OR
medium-dose
ICS
medium-dose
ICS
+
high-dose ICS
high-dose ICS
LABA
LABA
+
LABA
+
+
oral corticosteroids
medium-dose ICS
+
either LTRA or
theophylline§
Consider subcutaneous allergen immunotherapy for
patients who have persistent, allergic asthma.
high-dose ICS
high-dose ICS
either LTRA or
theophylline§
either LTRA or
theophylline§
+
+
+
oral corticosteroids
ƒƒ SABA as needed for symptoms. The intensity of treatment depends on severity of symptoms: up to 3 treatments
Quick-Relief
Medication
every 20 minutes as needed. Short course of oral systemic corticosteroids may be needed.
ƒƒ Caution: Increasing use of SABA or use 2 days/week for symptom relief (not to prevent EIB ) generally indicates
inadequate control and the need to step up treatment.
Intermittent
Asthma
Preferred
Treatment†
SABA as needed
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 care or higher is required. Consider consultation at step 3.
low-dose ICS
low-dose ICS
+
medium-dose
ICS
OR
LABA
AND
+
low-dose ICS
medium-dose ICS
AND
either LTRA,
theophylline,§
or zileuton‡‡
either LTRA,
theophylline,§
or zileuton‡‡
consider
omalizumab for
patients who
have allergies††
≥12 years of age
LABA
+
medium-dose ICS
Alternative
Treatment†,‡
cromolyn, LTRA,
or theophylline§
+
+
high-dose ICS
high-dose ICS
LABA
LABA
+
+
oral
corticosteroid§§
consider
omalizumab for
patients who
have allergies††
Consider subcutaneous allergen immunotherapy
for patients who have persistent, allergic asthma.
ƒƒ SABA as needed for symptoms. The intensity of treatment depends on severity of symptoms: up to 3 treatments
Quick-Relief
Medication
every 20 minutes as needed. Short course of oral systemic corticosteroids may be needed.
ƒƒ Caution: Use of SABA 2 days/week for symptom relief (not to prevent EIB ) generally indicates inadequate control
and the need to step up treatment.
Abbreviations: EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; LABA, inhaled long-acting beta2-agonist; LTRA, leukotriene receptor antagonist; SABA, inhaled
short-acting beta2-agonist.
† Treatment options are listed in alphabetical order, if more than one.
‡ f alternative treatment is used and response is inadequate, discontinue and use preferred treatment before stepping up.
I
§
T
heophylline is a less desirable alternative because of the need to monitor serum concentration levels.
B
ased on evidence for dust mites, animal dander, and pollen; evidence is weak or lacking for molds and cockroaches. Evidence is strongest for immunotherapy with single allergens.
The role of allergy in asthma is greater in children than in adults.
†† linicians who administer immunotherapy or omalizumab should be prepared to treat anaphylaxis that may occur.
C
‡‡ ileuton is less desirable because of limited studies as adjunctive therapy and the need to monitor liver function.
Z
§§ efore oral corticosteroids are introduced, a trial of high-dose ICS + LABA + either LTRA, theophylline, or zileuton, may be considered, although this approach has not been studied
B
in clinical trials.
7

8. Low
Medium
1 neb†/day
3 nebs†/day
0.5 mg
1 neb†/day
1 neb† 2x/day
2.0 mg
≥3 inhs† 2x/day
720 mcg
N/A
320–480 mcg
2–3 puffs 2x/day
160 mcg
1 puff 2x/day
≥4 puffs 2x/day
≥480 mcg
† Abbreviations: DPI, dry powder inhaler (requires deep, fast inhalation); inh, inhalation; MDI, metered dose inhaler (releases a puff of medication); neb, nebule.
I
t is preferable to use a higher mcg/puff or mcg/inhalation formulation to achieve as low a number of puffs or inhalations as possible.
80 mcg/puff
Flunisolide MDI†
N/A
≥2 puffs 2x/day
1 puff 2x/day
1 puff/day
160 mcg/puff
N/A
≥3 puffs 2x/day
1–2 puffs/day
N/A
80 mcg/puff
N/A
320 mcg
N/A
1 puff am,
2 puffs pm–
2 puffs 2x/day
Ciclesonide MDI†
160–320 mcg
1.0 mg
1 neb†/day
1 neb† 2x/day
1.0 mg
2 inhs† 2x/day
3–4 inhs† 2x/day
360–720 mcg
≥3 puffs 2x/day
320 mcg
High
80–160 mcg
2 nebs†/day
2 nebs†/day
1 neb†/day
0.25 mg
0.5 mg
1 neb† 2x/day
1.0 mg
1–2 nebs†/day
0.5–1.0 mg
1–2 inhs† 2x/day
180–360 mcg
0.25–0.5 mg
N/A
Budesonide Nebules
180 mcg/
inhalation
90 mcg/inhalation
Budesonide DPI†
N/A
2 puffs 2x/day
1 puff 2x/day
80 mcg/puff
N/A
3–4 puffs
2x/day
Beclomethasone MDI†
1–2 puffs
2x/day
N/A
High
40 mcg/puff
N/A
Medium
160–320 mcg
N/A
Low
5–11 years of age
80–160 mcg
MEDICATION
Daily Dose
0–4 years of age
2 puffs 2x/day
320 mcg
1–2 puffs 2x/day
160–320 mcg
N/A
1 inh† am,
2 inhs† pm
1–3 inhs† 2x/day
3–4 puffs 2x/day
320–640 mcg
2 puffs 2x/day
3–4 puffs 2x/day
320–640 mcg
N/A
2–3 inhs† 2x/day
540–1,080 mcg
2–3 puffs
2x/day
1 puff am,
2 puffs pm
180–540 mcg
4–6 puffs
2x/day
240–480 mcg
Medium
1–3 puffs
2x/day
80–240 mcg
Low
≥12 years of age
≥5 puffs 2x/day
640 mcg
≥3 puffs 2x/day
640 mcg
N/A
≥4 inhs† 2x/day
1,080 mcg
≥4 puffs
2x/day
480 mcg
High
ESTIMATED COMPARATIVE DAILY DOSAGES: INHALED CORTICOSTEROIDS FOR LONG-TERM ASTHMA CONTROL
8
Asthma Care Quick Reference

9. 2 puffs 2x/day
≥2 puffs
2x/day
352 mcg
High
1–2 puffs
2x/day
88–176 mcg
Low
264–440 mcg
Medium
440 mcg
High
N/A
N/A
1 inh†/day
110 mcg
1–2 inhs†/day
1–2 inhs† 2x/day
220–440 mcg
100–300 mcg
2 inhs† 2x/day
1–2 inhs† pm
ƒƒ Metered-dose inhaler (MDI) dosages are expressed as the actuator dose (amount
leaving the actuator and delivered to the patient), which is the labeling required in the
United States. This is different from the dosage expressed as the valve dose (amount
of drug leaving the valve, not all of which is available to the patient), which is used in
ƒƒ Some doses may be outside package labeling, especially in the high-dose range.
Budesonide nebulizer suspension is the only inhaled corticosteroid (ICS) with
FDA-approved labeling for children 4 years of age.
ƒƒ The most important determinant of appropriate dosing is the clinician’s judgment
of the patient’s response to therapy. The clinician must monitor the patient’s
response on several clinical parameters (e.g., symptoms; activity level; measures of
lung function) and adjust the dose accordingly. Once asthma control is achieved
and sustained at least 3 months, the dose should be carefully titrated down to the
minimum dose necessary to maintain control.
1 inh† pm
≥3 inhs† divided
in 2 doses
440 mcg
≥3 inhs† divided
in 2 doses
3–4 inhs† pm or
2 inhs† 2x/day
1 inh† 2x/day or
2 inhs† pm
≥3 inhs† 2x/day
220–440 mcg
≥2 inhs† 2x/day
≥3 inhs† 2x/day
500 mcg
ƒƒ For children 4 years of age: The safety and efficacy of ICSs in children 1 year of
age has not been established. Children 4 years of age generally require delivery of
ICS (budesonide and fluticasone MDI) through a face mask that fits snugly over nose
and mouth to avoid nebulizing in the eyes. Face should be washed after treatment
to prevent local corticosteroid side effects. For budesonide, the dose may be given
1–3 times daily. Budesonide suspension is compatible with albuterol, ipratropium,
and levalbuterol nebulizer solutions in the same nebulizer. Use only jet nebulizers, as
ultrasonic nebulizers are ineffective for suspensions. For fluticasone MDI, the dose
should be divided 2 times daily; the low dose for children 4 years of age is higher
than for children 5–11 years of age because of lower dose delivered with face mask
and data on efficacy in young children.
many European countries and in some scientific literature. Dry powder inhaler (DPI)
doses are expressed as the amount of drug in the inhaler following activation.
Therapeutic Issues Pertaining to Inhaled Corticosteroids (ICSs) for Long-Term Asthma Control
110–220 mcg
≥3 inhs† 2x/day
440 mcg
1 inh† 2x/day
1 inh† 2x/day
1–3 inhs† 2x/day
2 inhs† 2x/day
† Abbreviations: DPI, dry powder inhaler (requires deep, fast inhalation); inh, inhalation; MDI, metered dose inhaler (releases a puff of medication); neb, nebule.
I
t is preferable to use a higher mcg/puff or mcg/inhalation formulation to achieve as low a number of puffs or inhalations as possible.
220 mcg/inhalation
110 mcg/inhalation
Mometasone DPI†
N/A
2 inhs† 2x/day
1 inh† 2x/day
100 mcg/inhalation
250 mcg/inhalation
3–4 inhs† 2x/day
1–2 inhs† 2x/day
50 mcg/inhalation
400 mcg
300–500 mcg
200–400 mcg
N/A
Fluticasone DPI†
N/A
≥2 puffs 2x/day
N/A
1–3 puffs
2x/day
88–264 mcg
Low
1 puffs 2x/day
1 puff 2x/day
≥2 puffs 2x/day
352 mcg
High
220 mcg/puff
110 mcg/puff
1 puff 2x/day
3–4 puffs
2x/day
176–352 mcg
Medium
100–200 mcg
44 mcg/puff
3–4 puffs
2x/day
176–352 mcg
Medium
≥12 years of age
3 puffs 2x/day
176 mcg
Low
5–11 years of age
(continued)
2 puffs 2x/day
Fluticasone MDI†
MEDICATION
Daily Dose
0–4 years of age
ESTIMATED COMPARATIVE DAILY DOSAGES:
INHALED CORTICOSTEROIDS FOR LONG-TERM ASTHMA CONTROL
Asthma Care Quick Reference
9

10. 10
Asthma Care Quick Reference
USUAL DOSAGES FOR OTHER LONG-TERM CONTROL MEDICATIONS*
Medication
0–4 years of age
5–11 years of age
≥12 years of age
Combined Medication (inhaled corticosteroid + long-acting beta2-agonist)
N/A†
1 inhalation 2x/day; dose
depends on level of
severity or control
1 inhalation 2x/day; dose
depends on level of severity
or control
Budesonide/Formoterol —
MDI† 80 mcg/4.5 mcg or 160 mcg/4.5 mcg
N/A†
2 puffs 2x/day; dose
depends on level of
severity or control
2 puffs 2x/day; dose depends
on level of severity or control
Mometasone/Formoterol —
MDI† 100 mcg/5 mcg
N/A†
N/A†
2 inhalations 2x/day; dose
depends on severity of asthma
4 mg every night at
bedtime (1–5 years of age)
5 mg every night at
bedtime (6–14 years of age)
10 mg every night at
bedtime
N/A†
10 mg 2x/day
(7–11 years of age)
40 mg daily
(20 mg tablet 2x/day)
N/A†
N/A†
2,400 mg daily
(give 1 tablet 4x/day)
N/A†
N/A†
150–375 mg subcutaneous
every 2–4 weeks, depending
on body weight and
pretreatment serum IgE level
1 ampule 4x/day, N/A†
2 years of age
1 ampule 4x/day
1 ampule 4x/day
Starting dose 10 mg/kg/
day; usual maximum:
ƒƒ 1 year of age: 0.2 (age in
weeks) + 5 = mg/kg/day
ƒƒ ≥1 year of age:
16 mg/kg/day
Starting dose 10 mg/
kg/day; usual maximum:
16 mg/kg/day
Starting dose 10 mg/kg/day
up to 300 mg maximum;
usual maximum:
800 mg/day
Fluticasone/Salmeterol —
DPI† 100 mcg/50 mcg, 250 mcg/50 mcg, or
500 mcg/50 mcg
MDI† 45 mcg/21 mcg, 115 mcg/21 mcg, or
230 mcg/21 mcg
Leukotriene Modifiers
Leukotriene Receptor Antagonists (LTRAs)
Montelukast — 4 mg or 5 mg chewable tablet,
4 mg granule packets, 10 mg tablet
Zafirlukast — 10 mg or 20 mg tablet
Take at least 1 hour before or 2 hours after a meal.
Monitor liver function.
5-Lipoxygenase Inhibitor
Zileuton — 600 mg tablet
Monitor liver function.
Immunomodulators
Omalizumab (Anti IgE†) —
S
ubcutaneous injection, 150 mg/1.2 mL following
reconstitution with 1.4 mL sterile water for injection
Monitor patients after injections; be prepared to treat
anaphylaxis that may occur.
Cromolyn
Cromolyn — Nebulizer: 20 mg/ampule
Methylxanthines
Theophylline —
Liquids, sustained-release tablets, and capsules
Monitor serum concentration levels.
Inhaled Long-Acting Beta2-Agonists (LABAs) – used in conjunction with ICS† for long-term control; LABA is NOT to be used as monotherapy
Salmeterol — DPI† 50 mcg/blister
N/A†
1 blister every 12 hours
1 blister every 12 hours
Formoterol —DPI† 12 mcg/single-use capsule
N/A†
1 capsule every 12 hours
1 capsule every 12 hours
ƒƒ 0.25–2 mg/kg daily
ƒƒ 0.25–2 mg/kg daily
ƒƒ 7.5–60 mg daily in single
in single dose in a.m.
or every other day as
needed for control
ƒƒ Short course “burst”:
1–2 mg/kg/day, max 60
mg/d for 3–10 days
in single dose in a.m.
or every other day as
needed for control
ƒƒ Short course “burst”:
1–2 mg/kg/day, max 60
mg/d for 3–10 days
dose in a.m. or every other
day as needed for control
ƒƒ Short course “burst”: to
achieve control, 40–60 mg/
day as single or 2 divided
doses for 3–10 days
Oral Systemic Corticosteroids
Methylprednisolone — 2, 4, 8, 16, 32 mg tablets
Prednisolone — 5 mg tablets; 5 mg/5 cc, 15 mg/5 cc
Prednisone — 1, 2.5, 5, 10, 20, 50 mg tablets;
5 mg/cc, 5 mg/5 cc
* osages are provided for those products that have been approved by the U.S. Food and Drug Administration or have sufficient clinical trial safety and efficacy data in the
D
appropriate age ranges to support their use.
† Abbreviations: DPI, dry powder inhaler; IgE, immunoglobulin E; MDI, metered-dose inhaler; N/A, not available (not approved, no data available, or safety and efficacy not
established for this age group).
The most important determinant of appropriate dosing is the clinician’s judgment of the patient’s response to therapy. The clinician
must monitor the patient’s response on several clinical parameters (e.g., symptoms; activity level; measures of lung function) and adjust
the dose accordingly. Once asthma control is achieved and sustained at least 3 months, the dose should be carefully titrated down to the
minimum dose necessary to maintain control.

11. Asthma Care Quick Reference
RESPONDING TO PATIENT QUESTIONS ABOUT INHALED CORTICOSTEROIDS
Questions and varying beliefs about inhaled
corticosteroids (ICSs) are common and may affect
adherence to treatment. Following are some key
points to share with patients and families.
ƒƒ ICSs are the most effective medications for
long-term control of persistent asthma. Because
ICSs are inhaled, they go right to the lungs to
reduce chronic airway inflammation. In general,
ICSs should be taken every day to prevent asthma
symptoms and attacks.
ƒƒ The potential risks of ICSs are well balanced by their
benefits. To reduce the risk of side effects, patients
should work with their doctor to use the lowest dose
that maintains asthma control, and be sure to take the
medication correctly.
•• Mouth irritation and thrush (yeast infection),
which may be associated with ICSs at higher
doses, can be avoided by rinsing the mouth and
spitting after ICS use and, if appropriate for the
inhaler device, by using a valved holding chamber
or spacer.
•• ICS use may slow a child’s growth rate slightly.
This effect on linear growth is not predictable and
is generally small (about 1 cm), appears to occur
in the first several months of treatment, and is
not progressive. The clinical significance of this
potential effect has yet to be determined. Growth
rates are highly variable in children, and poorly
controlled asthma can slow a child’s growth.
ƒƒ ICSs are generally safe for pregnant women.
Controlling asthma is important for pregnant women
to be sure the fetus receives enough oxygen.
ƒƒ ICSs are not addictive.
ƒƒ ICSs are not the same as anabolic steroids that some
athletes use illegally to increase sports performance.
RESPONDING TO PATIENT QUESTIONS ABOUT LONG-ACTING BETA 2 -AGONISTS
Keep the following key points in mind when
educating patients and families about long-acting
beta2-agonists (LABAs).
ƒƒ The addition of LABA (salmeterol or formoterol) to the
treatment of patients who require more than low-dose
inhaled corticosteroid (ICS) alone to control asthma
improves lung function, decreases symptoms, and
reduces exacerbations and use of short-acting
beta2-agonists (SABA) for quick relief in most patients
to a greater extent than doubling the dose of ICS.
with those taking a placebo added to usual therapy.
Therefore, the Food and Drug Administration placed
a Black Box warning on all drugs containing a LABA.
ƒƒ The established benefits of LABAs added to ICS for the
great majority of patients who require more than lowdose ICS alone to control asthma should be weighed
against the risk of severe exacerbations, although
uncommon, associated with daily use of LABAs.
ƒƒ LABAs should not be used as monotherapy for
long-term control. Even though symptoms may
improve significantly, it is important to keep taking
ICS while taking LABA.
ƒƒ A large clinical trial found that slightly more deaths
occurred in patients taking salmeterol in a single
inhaler every day in addition to usual asthma therapy*
(13 out of about 13,000) compared with patients taking ƒƒ Daily use should generally not exceed 100 mcg
a placebo in addition to usual asthma therapy
salmeterol or 24 mcg formoterol.
(3 out of about 13,000). Trials for formoterol in a
single inhaler every day in addition to usual therapy*
ƒƒ It is not currently recommended that LABAs be used
found more severe asthma exacerbations in patients
to treat acute symptoms or exacerbations.
taking formoterol, especially at higher doses, compared
* Usual therapy included a wide range of regimens, from those in which no other daily therapy was taken to those in which varying doses of other daily medications were taken.
11

12. EDUCATIONAL RESOURCES
National Heart, Lung, and Blood Institute
ƒƒ Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3)
www.nhlbi.nih.gov/guidelines/asthma
ƒƒ Physician Asthma Care Education (PACE): www.nhlbi.nih.gov/health/prof/lung/asthma/pace/
ƒƒ National Asthma Control Initiative (NACI): http://naci.nhlbi.nih.gov
Allergy Asthma Network Mothers of Asthmatics
800–878–4403
www.aanma.org
American Lung Association
800–LUNG–USA (800–586–4872)
www.lungusa.org
American Academy of Allergy, Asthma,
and Immunology
414–272–6071
www.aaaai.org
American School Health Association
800–445–2742
www.ashaweb.org
American Academy of Pediatrics
847–434–4000
www.aap.org
American Association of Respiratory Care
972–243–2272
www.aarc.org
American College of Chest Physicians
847–498–1400
www.chestnet.org
American College of Allergy, Asthma Immunology
847–427–1200
www.acaai.org
For more information contact:
NHLBI Information Center
P.O. Box 30105
Bethesda, MD 20824–0105
Phone: 301–592–8573
Fax: 301–592–8563
Web site: www.nhlbi.nih.gov
NIH Publication No. 12-5075
Originally Printed June 2002
Revised September 2012
Asthma and Allergy Foundation of America
800–7–ASTHMA (800–727–8462)
http://aafa.org
Centers for Disease Control and Prevention
800–CDC–INFO (800–232–4636)
www.cdc.gov/asthma
Environmental Protection Agency/
Asthma Community Network
www.asthmacommunitynetwork.org
800–490–9198 (to order EPA publications)
www.epa.gov/asthma/publications.html
National Association of School Nurses
240–821–1130
www.nasn.org